Emergency Ultrasound (EUS)教學(14)

急診超音波在胸腔急症之應用
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
 Why such a delay for lung
ultrasound to become popular ?
 Principles of Lung Ultrasound
1. Dependent versus Nondependent disorders
2. Lung surface is extensive
3. All lung signs arise from the pleural line
4. Analyze artifacts
5. Dynamic signs
6. Acute disorders contact the thorax surface
7. A simple & 2-D device meets this task
 Earth-Sky Axis
• Fluids want to descent, gases to rise.

• Lung disorders
– Dependent: PLE, consolidation, ….
– Non-dependent: PTX, interstitial syndrome, ….

• Define the scanning situation

Patient position
 Landmarks of the chest wall
• Lung surface: 1500cm2
• Position: as stethoscope
• 9 areas
– Anterior zone (1-4)
– Lateral zone (5,6)
– Posterior zone (S,M,L)
• 4 stages
– 1. anterior
– 2. lateral
– 3. portion of posterior
– 4. posterior
 Landmarks of the chest wall
• Lung surface: 1500cm2
• Position: as stethoscope
• 9 areas
– Anterior zone (1-4)
– Lateral zone (5,6)
– Posterior zone (S,M,L)
• 4 stages
– 1. anterior
– 2. lateral
– 3. portion of posterior
– 4. posterior
 Degree of aeration and US signs

Key concepts: Air versus Water

Degree Pathologic disorder Ultrasound pattern

100% Pneumothorax A lines & Lung sliding (-)
98% Normal lung A lines & Lung sliding (+)
95% Thickening of the interlobular septa B7 lines
80% Ground-glass areas B3 lines
10% Alveolar consolidation Hepatization & air bronchograms (++)
5% Atelectasis Hepatization & air bronchograms (-)
0% Pleural effusion Anechoic collection
Normal Landmark
Bat sign

Rib

Pleural line

A-line
 Normal dynamic lung pattern
Lung sliding: all-or-nothing rule
”Seashore sign”

 Rule out pneumothorax

 Normal static lung pattern
A line & B line

A lines and B lines cannot be visible at the same location

Comet-tail artifact
APE versus Normal
 Comet-tail artifact
”Lung rockets”

B-line

Rule out pneumothorax

Indicate interstitial syndrome
Normal versus APE
Comet –tail artifact

Z-line
Comet-tail artifact

E-line

 Parietal emphysema
 Clinical applications
• Pleural effusion
• Pneumothorax
• Alveolar consolidation
• Interstitial syndrome
• Airway control
• Others
 Pleural Effusion

1. Anechoic pattern
2. Static: Sharp sign
3. Dynamic: Sinusoid sign
Discrepant results
The Sharp Sign
The Sinusoid Sign
core-surface axis
 US application in pleural effusion
• Detect the effusion
• Evaluate its volume • Visual approach rule
– Interpleural space :≧15mm
• Reveal its nature
– No interposed organs
• Locate tapping area – Locate safe route/depth

• Withdrawal pleural effusion

– Improve ventilatory mechanics
– Assist weaning
Pneumothorax
Rule out pneumothorax
all-or-nothing rule
 Stratosphere sign (Barcode Sign)

Lung sliding (-)

Sensitivity 100%
Specificity 78%

A line sign
(No B line)

Sensitivity 100%
Specificity 60%

 Pneumothorax
Sensitivity 66%
Lung point
Specificity 100%

 Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
Explanation of lung point
Sensitivity 66%
Lung point
Specificity 100%

 Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440
• Setting: MICU
• Patients:
– PTX: 43
– Control:68
• Intervention: supine analysis of anterior chest
wall
• Results:
– Feasibility 98.1%
– Sensitivity 95.3%
– Specificity 91.1%
– NPV 100%

Lichtenstein DA, et al. Chest 1995;108:1345-48

Lichtenstein DA, et al. Inten Care Med 1997;25:383-388
Sensitivity 93%
Specificity 100%

 Rule out Pneumothorax

 Accuracy of US for PTX
Pneumothorax Control Group
Lung sliding (-) 43 of 43 65 of 302
LS (-) + A line sign 41 of 43 16 of 302
LS (-) + A line sign + lung point 34 of 43 0 of 302
Sensitivity, % Specificity, %
LS (-) 100 78
LS (-) + A line sign 95 94
LS (-) + A line sign + lung point 79 100

Lichtenstein DA, et al. CCM 2005;33:1231-1238

Power slide sign
 Algorithm for PTX
1. Recognition of PTX
(Emergency or Pre-hospital)
2. Visual approach drainage
3. Monitoring evolution
4. Post-intervention F/U
5. Pregnancy/Children consideration
 Algorithm for PTX
1. Recognition of PTX (Emergency or Pre-hospital)
2. Visual approach drainage
3. Monitoring evolution
4. Post-intervention F/U
5. Pregnancy/Children consideration
Alveolar Consolidation

98.5% of cases abut the pleura

Sensitivity 90%/ Specificity 98%
 Alveolar consolidation
• Locate in the thorax • Air bronchogram
• Arise from the pleural line – Dynamic
or associated PLE • pneumonia
– Static
• Tissue-like pattern
• Atelectasis
• Static • Lung pulse
– Irregular deep boundary
• Dynamic • Assess volume
– Absence of any sinusoidal • Detect abscess or
component necrotizing areas
Hepatization & Air Bronchogram
C line
 Interstitial Syndrome

Thickening of interlobular septa (B7 lines)

Ground-glass areas (B3 lines)
 B versus b line

Lung rockets
 Comet-tail artifact
Lung rockets

B-line

Rule out pneumothorax

Indicate interstitial syndrome
D/D APE & COPD with AE (Sen 100%/Spe 92%)
Normal versus APE

US B lines ～ Kerley B lines

Comet-tail artifacts
Aurora sign
Be careful
Airway Control
Sensitivity 93%
Specificity 100%

Rule out Pneumothorax

Possible one lung intubation
Endotracheal tube confirmation
Endotracheal tube confirmation
Others
Comet-tail artifact

E-line

 Parietal emphysema
Sternal fracture

J Ultrasound Med 2006;25:1263-1268

Rib fracture
US may replace post-interventional
radiography
Lung Contusion
Pulmonary embolism

Chest. 2005;128:1531-1538
Pulmonary embolism

Chest. 2005;128:1531-1538
 Advantages of US for PTX
• High feasibility
• High sensitivity
• Rapidity
• Ability to predict the extent of pneumothorax
• Simple technique
• Short learning curve
• Simple logistics
• Wide-ranging applications
• Non-invasive method
 Limitations and pitfalls of US
• Parietal emphysema
• Posterior locations of pneumothorax
• Anterior septate pneumothorax
• Imperfect specificity of certain signs
• Dyspnea
• Large dressings
• Technical errors
 Clinical consideration
• Lung US: answer to the traditional quandary of
radiography or CT in the ICU
• Approach to a dyspneic patient
• A field to be defined: For whom ?
• A field to be defined: By whom ?
• Lung US: a space for simplicity
• Versatility: an access to the neighboring organs
• Hamlessness, Cost savings
• Limitations of lung US
• Training in lung US